Existing tools to assess the risk of fracture in older adults appear to work for individuals with type 2 diabetes, researchers found.

Action Points

Explain that both the femoral neck bone mineral density T-score and the World Health Organization Fracture Risk Algorithm (FRAX) score were significantly associated with fracture risk in patients with diabetes.

Note that for any given T-score or FRAX score, the risk of fracture was higher in patients with diabetes than in those without diabetes.

Existing tools to assess the risk of fracture in older adults appear to work for individuals with type 2 diabetes, researchers found.

Both the femoral neck bone mineral density T-score and the World Health Organization Fracture Risk Algorithm (FRAX) score were significantly associated with fracture risk in patients with diabetes, according to Ann Schwartz, PhD, of the University of California at San Francisco, and colleagues.

However, they reported in the June 1 issue of JAMA that for any given T-score or FRAX score, the risk of fracture was higher in patients with diabetes than in those without diabetes.

"Our results indicate that femoral neck bone mineral density and the FRAX score are as useful for the assessment of fracture risk in older adults with type 2 diabetes as in those without type 2 diabetes," the authors wrote. "However, interpretation of T-score or FRAX score in an older patient with type 2 diabetes must take into account the higher fracture risk associated with type 2 diabetes."

Bone mineral density T-scores, either alone or when incorporated into the FRAX score, predict fracture risk in older adults, although it was not known whether they would predict risk in patients with diabetes, who have been shown to have higher bone mineral density but also a higher fracture risk than other individuals.

To explore the issue, Schwartz and her colleagues analyzed data from three prospective observational studies of older men and women: the Study of Osteoporotic Fractures, the Osteoporotic Fractures in Men Study, and the Health, Aging, and Body Composition (Health ABC) study. The studies collectively included 9,449 older women and 7,436 older men in the U.S.

The FRAX score was not calculated for the Health ABC study. This score includes femoral neck bone mineral density T-score, age, sex, body mass index, previous history of fracture, parental history of hip fracture, current smoking, recent use of corticosteroids, presence of rheumatoid arthritis, and alcohol consumption.

Overall, 770 women and 1,199 men had diabetes. During a mean follow up of 12.6 years for women and 7.5 years for men, 84 women and 32 men had at least one hip fracture and 262 women and 133 men had at least one nonspine fracture.

Both femoral neck bone mineral density T-score and FRAX score were associated with fracture risk in patients with diabetes.

Among women with diabetes, the age-adjusted hazard ratios (HR) for every 1-unit decrease in femoral neck bone mineral density T-score were 1.88 (95% CI 1.43 to 2.48) for hip fracture and 1.52 (95% CI 1.31 to 1.75) for nonspine fracture. The corresponding HRs for men with diabetes were 5.71 (95% CI 3.42 to 9.53) and 2.17 (95% CI 1.75 to 2.69).

The HRs for every 1-unit increase in FRAX hip fracture scores were 1.05 (95% CI 1.03 to 1.07) for women with diabetes and 1.16 (95% CI 1.07 to 1.27) for men with diabetes. The findings were similar for the FRAX osteoporotic fracture scores.

The ability of femoral neck bone mineral density T-score to predict fracture risk was similar in older men and women with and without diabetes, but the FRAX score tended to underestimate long-term fracture risk in diabetics of both sexes.

"To be widely useful, the FRAX score must necessarily be as brief as possible," Schwartz and her colleagues wrote. "However, an adjustment of this algorithm for type 2 diabetes seems justified, given the prevalence of diabetes among older adults."

The authors also pointed out that for any given fracture risk, patients with diabetes had a higher bone mineral density T-score than those without diabetes.

For example, when assessing the risk of hip fracture, the estimated T-score was, on average, 0.59 points higher for women with diabetes and 0.38 for men with diabetes.

So, the researchers wrote, "refinements are needed in current treatment and diagnostic algorithms for use in older patients with type 2 diabetes."

They acknowledged some limitations of the analysis, including the lack of glucose measurements in one of the studies, which could lead to misclassification of diabetes status; the lack of information on vertebral fractures; and the lack of adjustment for duration of diabetes.

The study was funded by an investigator-initiated grant from Amgen. The Study of Osteoporotic Fractures is supported by the NIH. The National Institute on Aging provides support under several grants. The Osteoporotic Fractures in Men study is supported by the NIH and by a grant from the American Diabetes Association. The National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Aging, the National Center for Research Resources, and the NIH Roadmap for Medical Research provided support under several grants. The Health, Aging, and Body Composition study is supported by contracts and a grant from the National Institute on Aging; by a grant from the National Institute of Nursing Research; and by the Intramural Research Program of the NIH, National Institute on Aging.

The funding organizations were independent of the design and conduct of the study, the collection, management, analysis, and interpretation of the data, and the preparation of the manuscript. Before submission for publication, the manuscript was reviewed by Amgen and was reviewed and approved by the National Institute on Aging.

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